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Headache medications

Antidepressant use during pregnancy

By: Dr. Mauskop
30-04-2023
Brain disorders, Chronic migraine, Headache medications, Headaches, Headaches in children, Migraine, Pain, Psychology of headaches

Antidepressants are commonly prescribed to treat migraines, tension-type headaches, and various types of chronic pain. Migraines primarily affect women of reproductive age, and those who suffer from migraines are more likely to develop anxiety and depression compared to those without migraines. This may be another reason why someone with migraines might be prescribed an antidepressant. Women who are pregnant or planning to become pregnant are understandably cautious about taking any medication.

Antidepressant use during pregnancy does not increase the risk of neurodevelopmental disorders in children, according to a new study published in JAMA Internal Medicine.

Antidepressant use during pregnancy has been associated with neurodevelopmental disorders in children in some studies. However, other factors such as the parent’s mental health status, genetics, and environmental factors may have influenced these results. The objective of this study was to evaluate the association between antidepressant use in pregnancy and neurodevelopmental outcomes in children.

The study looked at data from over 3 million pregnancies, tracking children from birth until outcome diagnosis, disenrollment, death, or the end of the study (maximum 14 years). There were 145,702 antidepressant-exposed pregnancies.

The study found no evidence to suggest that antidepressant use in pregnancy itself increases the risk of neurodevelopmental disorders such as autism spectrum disorder, attention-deficit/hyperactivity disorder, specific learning disorders, developmental speech/language disorders, developmental coordination disorders, intellectual disabilities, or behavioral disorders.

However, given the strong crude associations found in previous studies, antidepressant exposure during pregnancy may be an important marker for the need for early screening and intervention to modify factors that do increase such risk.

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Using AI to predict who will respond to placebo

By: Dr. Mauskop
16-04-2023
Headache medications, Headaches, Pain, Pain Research, Psychology of headaches

Placebo response is a bane of clinical trials but it can be very helpful in practice. A team of American and Canadian researchers used AI to help identify predictors of the placebo response. The results were recently published in Pain, under the title, Predicting placebo analgesia in patients with chronic pain using natural language processing: a preliminary validation study.

Since they used AI for their study, I thought it would be fitting to use ChatGPT to edit their abstract for the lay public.

Patients with chronic pain often experience significant pain relief from placebos (inert pills), and this effect can last for days or even weeks. However, it’s still unclear whether we can reliably predict who will respond to placebo and how to do so. Previous research has shown that people who respond well to placebos tend to talk about their pain and their life in a certain way. In this study, the researchers looked at whether these language patterns can predict who will respond to a placebo before they even receive the treatment, and whether we can distinguish between people who will respond to a placebo versus a real drug.

To do this, they analyzed language patterns from patients with chronic back pain who received a placebo in one study and used this information to build a language model that could predict who would respond to a placebo in a separate study. They found that this language model was able to predict, before treatment, which patients would respond well to a placebo in the second study. These patients reported an average of 30% pain relief from the placebo, while those predicted to be non-responders only experienced a 3% reduction in pain. However, the model was not able to predict who would respond to a real pain medication or who would recover without treatment, suggesting that it specifically predicts response to placebos.

Overall, this study suggests that we may be able to use language patterns to predict who will respond to placebos, which could help researchers design better clinical trials and improve patient care.

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The Top 10 Prophylactic Treatments for Migraines

By: Dr. Mauskop
20-03-2023
Botox, Chronic migraine, Headache medications, Migraine

In a recent post, I listed the top 10 acute treatments for migraine attacks that are mentioned in my book, The End of Migraines: 150 Ways to Stop Your Pain. Here is a list of the top 10 preventive drug therapies for migraines. In the next post, I will list the top 10 non-drug therapies.

The order of choices can vary depending on co-morbidities, potential side effects, cost, and other factors. For example, patients with coexistent anxiety and/or depression would have duloxetine and nortriptyline move higher on this list. Patients with rapid heartbeat, anxiety, or PTSD could start with nebivolol. Those with high blood pressure, could start with candesartan or nebivolol, and so on.

  1. OnabotulinumtoxinA (Botox)
  2. Atogepant (Qulipta)
  3. Rimegepant (Nurtec)
  4. Galcanezumab (Emgality)
  5. Nebivolol (Bystolic)
  6. Propranolol (Inderal)
  7. Candesartan (Atacand)
  8. Duloxetine (Cymbalta)
  9. Nortriptyline (Pamelor)
  10. Fremanezumab (Ajovy)
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Thank you for making The End of Migraines #1 Bestseller in Nervous System Diseases

By: Dr. Mauskop
14-03-2023
Alternative Therapies, Blocks, Botox, Brain disorders, Chronic migraine, Headache medications, Headaches, Migraine, Migraine in pregnancy, Psychology of headaches, Science of Migraine

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A new migraine drug and my top 10 acute treatments for migraines

By: Dr. Mauskop
13-03-2023
Chronic migraine, Headache medications, Headaches, Migraine

Zavegepant nasal spray (Zavzpret) was just approved by the FDA for the acute treatment of migraines. It belongs to the family of gepants. These drugs abort migraine attacks by blocking the CGRP receptor. CGRP (calcitonin gene-related peptide) is released during a migraine attack. Blocking this molecule or the receptor it attaches to relieves migraines in about 50% of people.

There are four CGRP monoclonal antibodies, or mAbs, that are injected once every one or three months to prevent migraine attacks. Gepants are taken by mouth. Two of them – ubrogepant (Ubrelvy) and rimegepant (Nurtec) – are approved for the acute treatment of migraine attacks. Rimegepant, along with atogepant (Qulipta), is also approved for the prevention of migraines.

Nasal sprays to treat migraines have the advantage of faster onset of action. They are particularly useful for people who have nausea or vomiting and have difficulty absorbing or holding down oral medications. Other migraine drugs in a nasal spray include sumatriptan, zolmitriptan, dihydroergotamine, and ketorolac. For patients for whom these older drugs are ineffective, cause side effects, or are contraindicated, zavegepant could be a very good option.

If there are no contraindications for the use of a triptan (e.g. heart or other vascular diseases), I would use sumatriptan first because of the cost. It is also likely that insurance companies will require that the patient fails sumatriptan before they agree to pay for a new and more expensive drug. This is what they usually require before paying for oral gepants.

Here is a list of what I consider to be the top 10 acute medications to treat migraine from the second edition of my book, The End of Migraines: 150 Ways to Stop Your Pain. I might add zavegepant to the next edition of this book.

  1. Sumatriptan
  2. Rizatriptan
  3. Eletriptan
  4. Naratriptan
  5. Zolmitriptan
  6. Rimegepant
  7. Ubrogepant
  8. Aspirin/caffeine/acetaminophen
  9. Naproxen
  10. Ibuprofen
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Attend the Migraine World Summit!

By: Dr. Mauskop
09-03-2023
Alternative Therapies, Botox, Chronic migraine, Headache medications, Headaches, Migraine

I am honored to speak at this year’s Migraine World Summit on Sunday, March 12. My topic is Safety Update: DHE, Triptans, Magnesium, Butterbur, and more.

The Migraine World Summit gives you a chance to improve your understanding of migraine headaches. 2023 dates: March 8-16. Register for free access at MigraineWorldSummit.com   Call: 8885256449,   Email: info@migraineworldsummit.com   Facebook: www.facebook.com/MigraineWorldSummit/    Instagram: @migrainesummit

 

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Predicting response to migraine treatment

By: Dr. Mauskop
05-03-2023
Chronic migraine, Headache medications, injections, Migraine

Updated on 3/5/23

Even the best migraine medications work for only about half of the people who try them. In the next decade or so, advances in pharmacogenomics, neuroscience, and artificial intelligence will allow us to predict who is going to respond to which drug. This will eliminate the trial-and-error approach we have to use now.

German researchers led by Dr. Uwe Reuter just published a study that attempts to predict who is going to respond to injections of CGRP monoclonal antibodies (mAbs) that are used for the prevention of migraines. These drugs include erenumab (Aimovig), galcanezumab (Emgality), and fremanezumab (Ajovy). The fourth drug in this family that is given intravenously, eptinezumab (Vyepti) was not available in Germany at the time of the study.

They compared super-responders (patients with 75% or greater reduction of monthly headache days) with non-responders (patients with 25% or lower reduction of monthly headache days after trying all three mAbs). Of 260 patients with chronic and episodic migraine they evaluated, 11% were super-responders, and 10% were non-responders.

Non-responders were more likely to have chronic migraines. Super-responders were significantly more likely to report good improvement of their acute migraine headache with a triptan. Non-responders were more likely to have depression and overuse acute medications.

It was interesting that only 10% of patients were non-responders. The authors explained this by the fact that they had to fail all three mAbs to be considered non-responders. An earlier German study showed that one-third of patients who did not respond to erenumab did respond to galcanezumab or fremanezumab.

The low number of super-responders to mAbs could be due to the fact that the German government pays for this treatment only if there is treatment failure or intolerable adverse events with all first-line preventives (beta-blockers, topiramate, flunarizine, amitriptyline and for chronic migraine, also OnabotulinumtoxinA, or contraindications to those. In the large clinical trials that led to the approval of mAbs, there was no such requirement and the results were much better.

Another study recently published by Sait Ashina and others in Rami Burstein’s group at Harvard showed that people who have increased skin sensitivity between migraine attacks (allodynia) are more likely to respond to galcanezumab.

These studies describe only trends and at this time have limited practical application. Patients who are depressed, overuse acute drugs, suffer from chronic migraines, or have interictal allodynia may still respond to mAbs. This information, however, may lead to more accurate prediction models when it is combined with genetic, imaging and other new data.

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An instructive case of dramatic relief of migraines

By: Dr. Mauskop
26-02-2023
Chronic migraine, Headache medications, Migraine, Science of Migraine

On March 10, I will be speaking on the Treatment of a Refractory Headache Patient at the annual meeting of HCNE in Greenwich, CT. One of the seven broad strategies I will be speaking about is trying multiple drugs within each therapeutic category. For example, if you did not respond to one beta-blocker, a different one might work better or have fewer side effects. Here is a part of a recent email from a former patient that supports this idea.

“For over fifty years, I have had migraines. Ever since Imitrex came out and I started to take it, I would get a migraine every day! We thought it might be rebound headaches from the Imitrex, but it was not. I tried every kind of medicine, and I mean EVERY. Nothing worked, and I just figured this was the way it would be until I died.
This summer, my hand was hurting and the doctor prescribed Celebrex. It did not help my hand, but my migraines WENT AWAY!!! Yes, after 50 some-odd years, no migraines. I thought it was a fluke, but no… my migraines are gone.
I take a Celebrex every morning after breakfast. If I even start to feel a headache, I take 2 Advil, and the headache is gone for the day. Every once in a while, I do get a migraine and I will take sumatriptan, but it is rare.”

Celebrex, or celecoxib, belongs to the NSAID family. It is somewhat different from other NSAIDs in that it is a selective COX-2 inhibitor. This means that it has fewer gastrointestinal side effects (ulcers, heartburn, etc.). Many people find that one NSAID works for an acute migraine much better than another – naproxen is better than ibuprofen, or diclofenac is better than naproxen, etc. This also holds true for the use of NSAIDs in the prevention of migraines. Meloxicam, indomethacin, aspirin, mefenamic acid, and others have been reported to be uniquely effective for some of my patients.

You can read about almost every drug in every category in the second edition of my latest book, The End of Migraines: 150 Ways to Stop Your Pain.

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More on Zinc – could help migraines

By: Dr. Mauskop
16-02-2023
Alternative Therapies, Botox, Brain disorders, Headache medications, Headaches, Migraine

In a post last August, I mentioned that zinc could possibly extend the duration of the effect of Botox. A new report by Chinese neurologists in Headache describes their findings of an inverse association between dietary zinc intake and the occurrence of migraine in American adults.

The researchers used the data from a five-year study conducted by the CDC to assess the health and nutritional status of Americans. Data were collected using a computer-assisted dietary interview system which proved to be very reliable. Over 11,000 adults were included in the analysis of zinc intake. These subjects were divided into quintiles, according to their zinc intake. The data were adjusted for various confounding factors. These included age, sex, race, ethnicity, smoking status, body mass index, and others.

People in the lowest quintile were at least 30% more likely to suffer from migraine compared to people in the other four quintiles. Associaion does not mean causation and this study does not prove that taking zinc will prevents migraines. However, a few small studies did show the benefit of taking a zinc supplement in migraine patients.

Checking your blood for zinc levels before taking a supplement would be ideal. However, there is very little downside to taking 10-25 mg of zinc daily even if you don’t know your zinc level.

Zinc is very important for the normal functioning of the immune system, it possibly prevents macular degeneration, and has many other benefits.  Taking too much zinc can cause serious side effects. The effects of zinc toxicity are mostly due to the lowering of copper levels.

 

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GABA supplement for anxiety and insomnia

By: Dr. Mauskop
05-02-2023
Alternative Therapies, Headache medications, Pain, Science of Migraine

GABA, or gamma-aminobutyric acid, is a popular supplement for the relief of anxiety and insomnia. Until recently, I was not recommending it to my patients. There are no scientific studies showing that it works. So why did I start recommending it? A report by a single patient, or as we say in scientific literature, an N of 1.

This 65-year-old woman had been suffering from anxiety from a young age. When her summer camp friends would write down everyone’s most common sayings, hers was, “I am so nervous”. This sense of anxiety persisted throughout her life. She is a successful career woman with a loving family. After a death in her family, she started seeing a psychologist who suggested taking GABA for insomnia. Within days, she was overcome by a sense of calmness she never experienced in her life. It’s been several months now and she remains calmer than ever before.

Certainly, this could be a placebo effect. In addition to the lack of controlled clinical trials, it is not even clear if GABA gets into the brain by crossing the so-called blood-brain barrier (BBB). It is possible, however, that it does not have to cross BBB. There is evidence that GABA may work through the enteric nervous system (ENS) – nerve endings lining the intestines. Both GABA and its receptors are widely distributed in the gut. Certain probiotics such as Lactobacillus and Bifidobacterium were found to increase GABA concentrations in the ENS. Probiotics have been shown to improve mood. This effect may be occurring through the vagus nerve. Vagus nerve is a large nerve that connects the intestines and all internal organs with the brain. It was somewhat of a surprise that vagus nerve stimulation at the neck level was proven (and FDA-approved) to relieve refractory depression and epilepsy.

GABA has been a popular supplement for many years. This obviously does not prove that it really works. However, it is very safe and relatively inexpensive. I would consider trying it before taking a prescription drug for anxiety or insomnia. Those can have significant side effects and in a 65-year-old may increase the risk of Alzheimer’s disease. And I always recommend regular exercise and meditation before any supplements.

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The review of my book, “The End of Migraines: 150 Ways to Stop Your Pain” by Lisa Robin Benson

By: Dr. Mauskop
31-01-2023
Alternative Therapies, Headache medications, Migraine, Migraine in pregnancy, New treatments, Science of Migraine

Thank you, Lisa Robin Benson for a kind review of my book. This is a video review on the Migraine.com website.

Many of my colleagues have written very positively about my book. It is even more gratyfing to hear that patients and patient advocates also find it useful.

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Attend an excellent headache course for health care providers in San Diego

By: Dr. Mauskop
11-01-2023
Alternative Therapies, Botox, Chronic migraine, Cluster headaches, Headache medications, Headaches, Migraine, New treatments, Psychology of headaches, Science of Migraine

Opportunities & Challenges in the Management of Headache is one of the two annual courses organized by the Diamond Headache Clinic Research & Educational Foundation. This year, it will be held in San Diego from February 16th through February 19th.

The other annual event, Headache Update 2023 will be held in Orlando, Fl from July 13th through July 16th. Both courses have been always well attended and have been receiving very high marks from the attendees.

It’s been my privilege to participate in these annual courses over the past 25 years. This year I will be speaking on February 17th on Nutritional Approaches and Alternative Therapies in Migraine.

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